Pertanyaan:

1.Bagaimana interpretasi umur kehamilan pasien dan riwayat kehamilannya?

2.Mengapa pasien mengeluarkan flek hitam dan merasa mulas? Apakah itu tanda akan melahirkan?

3.Apa penyakit yang berhubungan dengan tensi tinggi dan hipertensi dengan kehamilan?

4.Apa pengobatan rutin hipertensi yang bisa diberikan kepada ibu hamil?

5.Bagaimana interpretasi pemeriksaan tanda vital pasien? Mengapa bisa didapatkan edema?

6.Bagaimana interpretasi pemeriksaan abdomen? Jelaskan secara rinci

7.Apa kemungkinan yang bisa dieksklusi jika pada pasien didapatkan hasil negatif pada pemeriksaan
proteinuria? Kalau positif kemungkinan diagnosisnya apa?

8.Dari pemeriksaan obstetrik, apa yang bisa didapatkan (pada kala berapa pasien)?Apakah 6 jam untuk
memasuki kala tersebut adalah waktu yang normal? Berapa durasi tiap kala?

9.Bagaimana interpretasi partograf, ruptur perineum derajat 2, dan skor APGAR?

10.Apakah definisi dan indikasi ekstraksi vakum?

1. Lalalala
2. The most common cause for brown discharge is irritation. The surge of hormones and increased
blood flow throughout your body during pregnancy makes the cervix super sensitive, and sex
during pregnancy or a pelvic exam can aggravate it. That results in a bit of brown discharge or
light spotting.

If you’re nearing the end of your pregnancy, brown discharge could also be a sign that labor is
near. A couple of weeks to a few days before you give birth, you’ll lose your mucous plug (a glob
of mucus that seals off the opening of the cervix during pregnancy).

And in the days just before labor, you’ll likely see “bloody show,” or discharge tinged pink or
brown with blood, which means your baby’s arrival is imminent. If you suspect you’re
experiencing bloody show, call your health care provider immediately.

3. Fisiologi naiknya tekanan darah ibu hamil : The hormonal changes of pregnancy induce
significant adaptations in the cardiovascular physiology of the mother.24 Beginning early in the
first trimester, there are surges of estrogen, progesterone, and relaxin (hormone that, like
progesterone, mediates nitric oxide release), leading to systemic vasodilation.25–27
Concurrently, the renin–angiotensin–aldosterone system (RAAS) is augmented to engender salt
and water retention, leading to an expansion in plasma volume.28 This, combined with an
increased ventricular wall mass, leads to an increased stroke volume.29 The expansion in plasma
blood volume also results in a physiologic anemia, as the rate of increase is faster than that of
the increase in red blood cell mass.30 In order to compensate for the aforementioned systemic
vasodilation and physiologic anemia, heart rate raises.29 The combination of elevated stroke
 volume and tachycardia leads to an increase in cardiac output during pregnancy, which
compensates for the decline in vascular resistance in order to maintain blood pressure at high
enough levels for maternal and placental perfusion

Gestational hypertension is high blood pressure that you develop while you are pregnant. It starts
after you are 20 weeks pregnant. You usually don't have any other symptoms. In many cases, it does
not harm you or your baby, and it goes away within 12 weeks after childbirth. But it does raise your
risk of high blood pressure in the future. It sometimes can be severe, which may lead to low birth
weight or preterm birth. Some women with gestational hypertension do go on to develop
preeclampsia.

Chronic hypertension is high blood pressure that started before the 20th week of pregnancy or before
you became pregnant. Some women may have had it long before becoming pregnant but didn't know
it until they got their blood pressure checked at their prenatal visit. Sometimes chronic hypertension
can also lead to preeclampsia.

Preeclampsia is a sudden increase in blood pressure after the 20th week of pregnancy. It usually
happens in the last trimester. In rare cases, symptoms may not start until after delivery. This is called
postpartum preeclampsia. Preeclampsia also includes signs of damage to some of your organs, such as
your liver or kidney. The signs may include protein in the urine and very high blood pressure.
Preeclampsia can be serious or even life-threatening for both you and your baby.

4. Drugs for mild HTN

Beta-blockers
Beta-blockers (BB) are first-line medication during pregnancy and lactation. Labetalol is one of
the commonest drugs used in HDP. It can be used parenterally in cases of severe HTN. BB may
cause foetal bradycardia or intrauterine growth retardation; thus, proper monitoring of the
foetus is essential. Atenolol is better avoided during pregnancy [2].

Alpha methyldopa
This is an ᾳ2-adrenergic agonist that has central nervous system (CNS) and peripheral nervous
system effects. It is one of the safest drugs during pregnancy; been used for more than 40 years,
with no serious side effects on the mother or the foetus, although it has been largely displaced
by labetalol as the first-line agent of choice for most patients. The recommended daily dose of
methyldopa is 0.5–3.0 g in 2–4 doses. Side-effects include sleepiness, dry mouth, general
malaise, haemolytic anaemia, and hepatopathy [14].

Calcium channel blockers

Calcium channel blockers (CCBs) are among the recommended antihypertensive drugs during
pregnancy. Both dihydropyridines and non-dihydropyridines are allowed [2].

Diuretics
The use of diuretics during pregnancy carries a potential risk of oligohydramnios. Unless there is
a compelling indication for the use of diuretics (e.g., heart failure), their use is not
recommended. Diuretic therapy is better avoided in pre-eclampsia because the plasma volume
 is contracted [2]. Only loop diuretics are allowed, while thiazide and potassium-sparing diuretics
are contraindicated during pregnancy.

Renin-angiotensin-aldosterone system inhibitors

Renin-angiotensin-aldosterone system (RAAS) inhibitors include angiotensin-converting enzyme
inhibitors (ACEIs), angiotensin receptor blockers (ARBs), renin inhibitors, non-selective
(spironolactone) and selective (eplerenone) aldosterone antagonists.

Recent studies suggest that exposure early in pregnancy during the period of organogenesis
does not confer an increase in the risk of malformations [15]. However, animal and human data
suggest that RAAS inhibitor use during the second and third trimesters is associated with a
higher risk of complications, including renal dysplasia, pulmonary hypoplasia, and growth
restriction [16].

The guidelines recommend against the use of RAAS inhibitor drugs during pregnancy and
lactation (Class III recommendations). Beta-blockers are used as an alternative to ACEIs and
ARBs in younger hypertensive women planning pregnancy [1].

Drugs for severe HTN

HDP emergency is defined as BP ≥170/110 mmHg. It necessitates immediate hospital admission
and parenteral antihypertensive medications [2]. Intravenous labetalol and nicardipine as well
as oral methyldopa and CCB can be used. Hydralazine is now only used when other drugs fail to
control HTN, because of its increased perinatal adverse effects [17].

Treatment of pre-eclampsia/eclampsia syndrome

Women at a risk of developing pre-eclampsia should be advised to take 100–150 mg of aspirin
daily from weeks 12–36 gestation [18]. Aspirin can decrease the risk of pre-eclampsia by 12%
and the risk of premature delivery by 14% [19].
Women with a diagnosis of pre-eclampsia should be admitted and offered antihypertensive
medications, if not previously given. Intravenous labetalol and nicardipine are usually used to
lower the BP but foetal bradycardia is a concern. In case of pulmonary oedema, nitroglycerine
infusion is recommended. The consensus is to reduce BP to levels lower than 160/105 mmHg.
Intravenous magnesium sulfate is the treatment of choice in patients with eclampsia fits.
Delivery of the placenta (and the foetus, of course!) is the only cure for pre-eclampsia; yet, in
asymptomatic patients, delivery can be delayed to the 37th week of gestation.
During pregnancy, edema occurs when body fluids increase to nurture both you and your baby
and accumulate in your tissues as a result of increased blood flow and pressure of your growing
uterus on the pelvic veins and your vena cava (the large vein on the right side of your body that
returns blood from your lower limbs to your heart).

5. *Normal swelling* during pregnancy is most often experienced during the third trimester, when
standing or active for long periods of time, in the heat/summer, or when excess sodium or
caffeine is consumed.
abnormal swelling symptoms to be aware of:

- Swelling in your face and/or puffiness around your eyes

- Extreme swelling or sudden swelling in your hands, feet, or ankles
- Swelling accompanied by a headache that won't go away, vision changes, sudden nausea,
stomach, shoulder, or lower back pain, sudden weight gain, or shortness of breath (could signal
preeclampsia)
- Swelling more in one leg than the other, accompanied by pain or tenderness (could signal a
blood clot)
- Swelling accompanied by chest pain or difficulty breathing (could signal heart problems)

PATOLOGIS

The most common cause of edema in pregnancy is

 Physiologic edema

Physiologic edema results from hormone-induced sodium retention. Edema may also
occur when the enlarged uterus intermittently compresses the inferior vena cava during
recumbency, obstructing outflow from both femoral veins

Pathologic causes of edema are less common but often dangerous. They include

Pathologic causes of edema are less common but often dangerous. They include

 Deep venous thrombosis  (DVT)

 Preeclampsia
 Peripartum cardiomyopathy
 Cellulitis  (see table Some Causes of Edema During Late Pregnancy )

DVT is more common during pregnancy because pregnancy is a hypercoagulable state,

and women may be less mobile.

Preeclampsia results from pregnancy-induced hypertension; however, not all women with
preeclampsia develop edema.

Peripartum cardiomyopathy can cause other nonspecific symptoms of pregnancy, including

dyspnea and fatigue.

When extensive, cellulitis, which usually causes focal erythema, may resemble general
edema.
Non-severe hypertension. Any values between SBP 140–159 mmHg and DBP 90–109 mmHg.
Sometimes this category as a whole is termed “mild,” or it is further broken down into mild
(140–149/90–99 mmHg) and moderate (150–159/100–109 mmHg).13

Severe hypertension. SBP ⩾ 160 mmHg and/or DBP ⩾ 110 mmHg.14 Severe hypertension in
pregnancy has lower thresholds than in non-pregnant adults because pregnant women are
known to develop hypertensive encephalopathy at lower blood pressures

Proteinuria;

Other features of maternal organ dysfunction, including acute kidney injury (creatinine ⩾90
µmol/L; 1 mg/dL), liver involvement (elevated alanine aminotransferase or aspartate
aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain,
neurological complications (such as eclampsia, altered mental status, blindness, stroke, clonus,
 severe headaches, and persistent visual scotomata), and hematological complications
(decreased platelet count <150,000/μL, disseminated intravascular coagulation, hemolysis);

Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler
wave form analysis, or stillbirth).

Chronic/pre-existing hypertension with superimposed preeclampsia-eclampsia. Chronic

hypertension as defined above, that develops signs and symptoms of preeclampsia or eclampsia
after 20 weeks’ gestation.
6. Abdominal swelling, or distention, is more often caused by overeating than by a serious illness.
This problem also can be caused by:

Air swallowing (a nervous habit)

Buildup of fluid in the abdomen (this can be a sign of a serious medical problem)
Gas in the intestines from eating foods that are high in fiber (such as fruits and vegetables)
Irritable bowel syndrome
Lactose intolerance
Ovarian cyst
Partial bowel blockage
Pregnancy
Premenstrual syndrome (PMS)
Uterine fibroids
Weight gain

Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the
abdomen causing its expansion.[1] It is typically a symptom of an underlying disease or
dysfunction in the body, rather than an illness in its own right. People suffering from this
condition often describe it as "feeling bloated". Sufferers often experience a sensation of
fullness, abdominal pressure, and sometimes nausea, pain, or cramping. In the most extreme
cases, upward pressure on the diaphragm and lungs can also cause shortness of breath. Through
a variety of causes (see below), bloating is most commonly due to buildup of gas in the stomach,
small intestine, or colon. The pressure sensation is often relieved, or at least lessened, by
belching or flatulence. Medications that settle gas in the stomach and intestines are also
commonly used to treat the discomfort and lessen the abdominal distension.

presentasi kepala atau preskep. Dimana hal ini menunjukkan bahwa janin berada pada posisi
dimana kepala mengarah ke jalan lahir dan hal ini adalah presentasi yang normal ditemukan
pada saat bayi memasuki usia cukup bulan yaitu sekitar 34 minggu keatas sehingga mendukung
terjadinya persalinana secara normal. Bila terjadi presentasi lainnya maka perlu dilakukan
pertimbangan persalinan secara normal karena hal ini biasanya akan ada penyulit.
 pedoman dunia internasional menyatakan bahwa normal denyut jantung janin yang
direkomendasikan adalah 110-150 denyut per menit atau 110-160 denyut per menit. Namun di
lain sisi, sebuah penelitian menyatakan bahwa detak jantung janin yang normal berkisar antara
120-160 denyut tiap menit.Tujuan pemantauan ini adalah untuk membantu mendeteksi
perubahan pola detak jantung selama proses persalinan berlangsung. Pola detak jantung yang
terlalu cepat atau terlalu lambat menandakan kemungkinan adanya masalah pada janin, seperti
kekurangan oksigen.

7. LALALALALAL
8.
Penurunan Kepala Janin

Penilaian penurunan kepala dilakukan dengan menghitung proporsi bagian bawah

janin yang masih berada diatas tepi atas shypisi dan dapat diukur dengan lima jari
tangan (per limaan). Bagian diatas shumpisis adalah proporsi yang belum masuk
PAP.
1) 5/5 jika bagian terbawah janin seluruhnya teraba diatas shympisis pubis.
2) 4/5 jika sebagian (1/5) bagian terbawah janin telah memasuki PAP.
3) 3/5 jka sebagian (2/5) bagian terbawah janin telah memasuki PAP.
4) 2/5 jika hanya sebagian dari bagian terbawah janin yang masih berada diatas
shympisis dan (3/5) bagian telah masuk PAP.
5) 1/5 jika 1 dari 5 jari masih dapat meraba bagian terbawah janin yang berada
diatas shympisis dan 4/5 bagian telah masuk PAP.
6) 0/5 jika bagian terbawah janin sudah tidak dapat teraba dari pemeriksaan luar
dan bagian terbawah janin sudah masuk ke dalam rongga panggul (Widia, 2015 :
64-65).

c. Hodge
Bidang hodge adalah bidang semua sebagai pedoman untuk menentukan
kemajuan persalinan, yaitu seberapa jauh penurunan kepala melalui pemeriksaan
dalam/vagina toucher (VT). Bidang hodge terbagi menjadai 4, antara lain :
1) Bidang hodge I
Bidang setinggi pintu atas panggul (PAP) yang dibentuk oleh promotorium,
artikulasio sakro-iliaka, sayap sakrum, linea inominata, ramus superior os. Pubis,
tepi atas simfisis pubis.
2) Bidang hodge II
Bidang setinggi pinggir bawah simfisis pubis, berhimpit dengan PAP (Hodge I)
3) Bidang hodge III
Bidang setinggi ischiadika berhimpit dengan PAP (Hodge I).
4) Bidang hodge IV
Bidang setinggi ujung koksigis berhimpit dengan PAP (Hodge I).
9. Terdapat beberapa tingkatan dari ruptur perineum yaitu (Goh, Goh and Ellepola, 2018) :
1. Grade 1 : Laserasi terjadi pada mukosa vagina atau kulit perineum
2. Grade 2: Laserasi melibatkan otot pada perineum
3. Grade 3 : Ruptur grade 3 terbagi menjadi 3 kelompok
-Grade 3A : <50% otot sphincter ani eksternus mengalami rupture
-Grade 3B : >50% otot sphincter ani eksternus mengalami rupture
-Grade 3C : otot sphincter ani eksternus dan internus mengalami rupture
 4. Grade 4 : Robekan sampai ke mukosa

10. The indications for operative vaginal delivery are: protracted second stage of labor, suspicion of
immediate or potential fetal compromise, and shortening the second stage for maternal benefit.
It should be noted that these indications are relative, no absolute indications exist.